Volunteer Information
First Name Last Name

(H) (W) (C)

Street Address 1
Street Address 2
City State Zip Code

E-mail address

Placement Advisor Choose from the list of PAs below Ted Brown Jan Baker / Tom Lorenzo Steve Hanson Kay Habeger Eileen Sable Peggy Shomette Noel Sipple Jerry Inge

Has tutoring ended?
Yes No
If yes, date ended?

Reason tutoring ended

If you are not presently tutoring, are you available to tutor? Yes No

Does the student need another tutor?
Yes No

Would you like to be contacted to discuss other volunteer opportunities? Yes No

Student Information (if tutoring a group, please give the location and number of students instead)
First Name Last Name

Please fill out if changed:
Home Tel. Work Tel.

Street Address 1
Street Address 2
City State Zip Code

Jurisdiction
Arlington
Alexandria
Fairfax
Other (please specify)

I. VOLUNTEER HOURS

Total tutoring hours for this quarter
Tutor preparation and travel time
Trainer (include preparation & travel time)
Placement advisor/student interviewer
Workshop registration, in-service help
Board member
Other hours, please specify

II. BOOK LEVEL AT END OF QUARTER

Laubach Way to Reading
Level

Challenger Level

Wilson
Step

Reading for Today
Level

Voyager
Level

Other materials used:

III. COMMENTS
Please share how tutoring has affected you and your student, skills you are currently working on, or any special comments or concerns you may have.

IV. LIFE IMPROVEMENTS AND ACHIEVEMENTS (check any that apply)
Self confidence
Registered to vote
Got a job
Acquired citizenship
Job performance/advancement
Got a library card
Got a driver's license
Other (please specify):

V. PERSONAL LEARNING GOALS:
Please CHECK AT LEAST 3 goals that your student is currently working on. If a goal has been achieved this quarter, please check that box. Feel free to write in other goals.

SELF AND COMMUNITY
Working    Goal
On    Achieved
   1. Read and write own name, address, and phone number
   2. Read and write all letters of the alphabet
   3. Read a calendar
   4. Write appointments on a calendar
   5. Read and write simple telephone messages
   6. Use a telephone book
   7. Read a menu
   8. Write a shopping list
   9. Read and follow a recipe
   10. Read and interpret food labels
   11. Read mail
   12. Read and respond to a bill
   13. Write out checks or money orders
   14. Use bus/metro schedule
   15. Use written directions and/or a map to find a destination
   16. Read labels/directions on medicine bottles
   17. Read newspaper or magazine articles
   18. Read religious materials
   19. Read a book
   20. Find a word in the dictionary
   21. Understand the use of a table of contents
   22. Read and write cursive
   23. Write short personal letter to a friend
   24. Write short story or poem
   25. Use a computer
FAMILY
Working Goal
On Achieved
   26. Read to children
   27. Read/write notes to/from child's school
   28. Help children with school work
WORK
Working Goal
On Achieved
   29. Read job ads
   30. Fill out a job application or medical form
   31. Read and write messages related to work
   32. Fill out work forms, reports
   33. Pass a work-related test
OTHERS